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<table>
	<tr>
    	<td>товар</td>
    	<td colspan="2">&nbsp;<a href="#"><b>"Антивирус касперского 1221"</b></a></td>
    </tr>
	<tr>
    	<td>количество</td>
    	<td colspan="2"><input type="text" name="" width="30" value="1" /> шт.</td>
    </tr>
    
	<tr>
    	<td>E-Mail</td>
    	<td colspan="2"><input type="text" name="EMAIL" /></td>
    </tr>
	<tr>
    	<td>Телефон</td>
    	<td colspan="2"><input type="text" nane="TEL" /></td>
    </tr>
	<tr>
    	<td>организация</td>
    	<td><input type="text" nane="ORGANIZATION" /></td>
    	<td>
        	<select name="TYPE">
                <option value="GOS">Гос</option>
                <option value="fiz">Физ</option>
                <option value="ur">Юр</option>
            </select>
        </td>
    </tr>
	<tr>
    	<td colspan="3" align="center"><h1>ИЛИ</h1></td>
    </tr>
	<tr>
    	<td>тип организации</td>
    	<td align="left">
            <input type="radio" name="TYPE" value="" checked="checked" />Гос.учереждение<br>
            <input type="radio" name="TYPE" value="" />Физ. лицо<br>
            <input type="radio" name="TYPE" value="" />Юр лицо<br>
        </td>
        <td>&nbsp;</td>
    </tr>
    <tr>
    	<td>коментарий</td>
        <td colspan="2">
        	<textarea cols="33" rows="10"></textarea>
        </td>
    </tr>
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